Provider Demographics
NPI:1134392756
Name:GLUCK, LISA L
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:GLUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 DOUGHTY BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:INWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11096-2080
Mailing Address - Country:US
Mailing Address - Phone:516-295-4708
Mailing Address - Fax:516-295-3191
Practice Address - Street 1:148 DOUGHTY BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:INWOOD
Practice Address - State:NY
Practice Address - Zip Code:11096-2080
Practice Address - Country:US
Practice Address - Phone:516-295-4708
Practice Address - Fax:516-295-3191
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP3694131OtherOXFORD